Charting Course Of Health Care LegislationNow that the Senate Finance Committee has passed its health care overhaul bill, Senate Democratic leaders face the formidable task of pairing it with a more liberal bill passed earlier this year by another Senate committee. Then, they have to take it to the floor for debate.

Now that the Senate Finance Committee has passed its health care overhaul bill, Senate Democratic leaders face the formidable task of pairing it with a more liberal bill passed earlier this year by another Senate committee. Then, they have to take it to the floor for debate.

ROBERT SIEGEL, host:

Today in the Senate, the process of merging bills is just getting started.

NPR's Julie Rovner spent the afternoon up on Capitol Hill. And she joins us in the studio now with a merge progress report. Hiya.

JULIE ROVNER: Hiya.

SIEGEL: Seems the Republicans - it seems early to be talking about progress, but I gather there is a little bit.

ROVNER: There's a little bit of news. It seems that Republicans in the Senate, despite their modest numbers and the loss of Olympia Snowe of Maine who voted for the Finance bill, at least in committee yesterday, are coming out swinging. Senate Minority leader Mitch McConnell said after the weekly party lunches that Republicans will make sure that when this bill does get to the floor of the Senate, that it'd be debated for at least several weeks. Here's how he put it.

Senator MITCH MCCONNELL (Republican, Kentucky): The American people expect us to insist that we spend an adequate amount of time to explore all parts of this highly complex effort to reorganize one-sixth of our economy. And Senate Republicans are committed to making sure that that's a procedure that is followed.

SIEGEL: Is that capitolese for a filibuster, Julie?

ROVNER: Well, you need 40 votes to sustain a filibuster in the Senate and without Senator Snowe, they don't have 40 votes - they only have 39. But Republicans will try to make the case, as Senator McConnell said, that a bill as big as this deserves at least as much time on the floor being debated as an education bill like No Child Left Behind, which got seven weeks of debate, or last year's foreign bill, which was on the floor for a month.

SIEGEL: How are Democrats responding to that not-so-veiled threat?

ROVNER: Well, about like you would expect. You know, this bill has missed a lot of deadlines and while I don't think Democrats intend to have it on and off the Senate floor in just a few days, I think Democrats don't want the schedule dictated by the minority. Here's how Senate Majority leader Harry Reid responded when reporters asked him about Senator McConnell's comments.

Senator HARRY REID (Democrat, Nevada): I believe that the Republican leader and all his colleagues with the exception of a couple there, one of whom is Senator Snowe and there are a couple others, want to do anything that they can do not to have a bill. Remember, one Republican senator said he wants the health care bill to be President Obama's Waterloo, meaning his defeat.

ROVNER: That Republican Senator, by the way, was South Carolina's Jim DeMint.

SIEGEL: Yeah, this, though, is a challenge to Leader Reid to keep his party of the Democrats together to get a bill through the Senate. It sounds like it's going to take more than just implying, you know, criticizing Republicans.

ROVNER: That's right. Democrats are finding what Republicans found when they were in charge: the bigger your majority is the more diverse your coalition. So, there are liberals who are basically insisting that this bill include a government-run public plan as one option for people to choose. That's not in the Finance Committee bill, by the way, but it is in the Health Committee bill, the other Senate committee.

Then you've got more moderate members who are insisting that they won't vote for a bill that has a public option in it. Democrats thought for about a nanosecond that they'd found a compromise with these member-run co-ops, which are in the finance bill, but the Congressional Budget Office said that probably won't have much impact because not very many of those co-ops would even be created. So, that's a really big fight in these merger negotiations and whichever way it comes out is going to alienate a big block of those Democrats.

SIEGEL: Julie, when do you expect these negotiations to be complete in the Senate?

ROVNER: Well, of course, they had hoped to get the bill on the floor this week. That hasn't happened. And I think that no matter what happens in these negotiations, it's going to take longer than they had expected. That's been the rule with this bill. So, I think we've got at least a couple of weeks to go.

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What Will Make It Into The Final Senate Health Bill?

Senate Majority Leader Harry Reid testifies during a Senate Judiciary Committee hearing on Capitol Hill Wednesday. Reid also began private meetings Wednesday with fellow Democrats and the White House to merge his chamber's two health care overhaul bills into a single plan that could win a filibuster-proof majority in the Senate.
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Senate Majority Leader Harry Reid testifies during a Senate Judiciary Committee hearing on Capitol Hill Wednesday. Reid also began private meetings Wednesday with fellow Democrats and the White House to merge his chamber's two health care overhaul bills into a single plan that could win a filibuster-proof majority in the Senate.

Mark Wilson/Getty Images

Senate Majority Leader Harry Reid began private meetings Wednesday with fellow Democrats and the White House to merge his chamber's two health care overhaul bills into a single plan that could win a filibuster-proof majority in the Senate.

Work on combining the Senate's Finance and health committees' bills was supposed to be, in theory at least, the less contentious part of this new phase of overhaul negotiations. But the question of what will hit the Senate floor for debate in less than two weeks remains large and open.

Reid's task is complicated by the fact that although Senate Democrats enjoy a 60-vote, filibuster-proof majority, it is a fragile caucus that includes a handful of moderates whose votes on President Obama's signature domestic initiative are not a given.

And already at least one of Reid's fellow Senate Democrats, New York's Charles Schumer, is agitating for a final bill that includes a public insurance option — something missing from the measure passed this week by the more conservative Senate Finance Committee.

"In one sense, the debate begins all over again," says Bob Moffit, director of health policy studies at the conservative Heritage Foundation.

The long-awaited $829 billion proposal approved Tuesday by the Senate Finance Committee with a single Republican vote "concludes one big chapter of the health care debate," Moffit says. "But you're not going to see that bill again."

Opposition Pumps Up The Volume

Schumer wasn't the only one stirring the pot in the wake of Tuesday's vote.

Interest groups have ratcheted up their message machines this week — from insurers denouncing the Finance Committee proposal for failing to require that all Americans obtain coverage to unions balking at proposed taxes on generous benefit packages.

So Reid, with a tough re-election battle back home in Nevada and a looming showdown with House Speaker Nancy Pelosi over her chamber's competing legislation, has to devise a strategy that not only melds the Finance Committee's bill with the more liberal offering from the health committee but still gives the president a win.

There are a few certainties: There is little doubt that the ultimate Senate bill will include changes that prohibit insurers from denying coverage to Americans with pre-existing health conditions or canceling coverage when a policyholder gets sick.

And both Senate bills contain similar provisions for creating state-based insurance exchanges — or pools — that can be used by poor and low-income individuals and families, and small businesses, to purchase more affordable coverage.

The Finance Committee's plan to expand Medicaid coverage to more poor Americans is also expected to make the final bill, though details on how to pay for it — and for many other bill provisions — have yet to be worked out.

But the Finance Committee bill is the only proposal that does not include a government-run plan, and it does not require employers of a certain size to offer coverage to its employees.

"Do you impose an employer mandate that unions want, but employers will fight to the death?" Moffit asks. "Do you include a public plan that moderate Democrats don't want? Do you impose an individual mandate?"

Those big, fundamental questions are unanswered, says Michael Tanner, a senior fellow at Cato Institute. "There are real problems yet to be resolved," he says. "This is not even halfway there."

Different Mandates, Different Parameters

The Senate Finance Committee bill would require that most individuals obtain insurance, but its proposed phased-in penalties for failure to comply are nominal and would do little, critics argue, to encourage insurance purchase.

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It proposes that penalties of $200 per adult begin in 2014 and reach $750 by 2017. The Senate health committee has proposed a penalty of up to $750 a person, with no phase-in period.

The insurance industry had banked on a vastly increased pool of potential clients under a mandated-coverage plan. Now the industry is attacking the Finance Committee's proposal as guaranteeing an increase in the cost of premiums.

Also at odds are the competing Senate committee proposals for employer mandates, which have emerged as one of the stickiest issues Reid faces.

The Finance Committee would require that businesses with more than 50 employees foot the bill for government insurance subsidies for which their workers may qualify. The health committee bill demands that employers pay for part of the cost of worker coverage or face a penalty. Both bills include exemptions for small employers.

A merged Senate bill will very likely include both an individual and employer mandate, but just who will be exempted is expected to be one of the issues dominating closed-door sessions over the coming days.

Meeting Obama's Objectives Without A Public Option

Schumer may be pushing hard again for a public option to be included in the final Senate bill, but Obama suggested Tuesday that the Finance Committee bill — sans public option — brought Congress closer to achieving the president's core objectives: dramatically expanding the number of Americans covered by insurance, and bending the cost curve.

Len Nichols, director of the health policy program at the nonpartisan New America Foundation, said there has been "fertile thought" around an alternative to a full-blown public option.

That alternative, he says, could be some kind of a melding of so-called trigger proposals advocated by both Democratic Sen. Tom Carper of Delaware and Sen. Olympia Snowe of Maine, the only Republican on the Finance Committee to vote for the proposed overhaul plan.

Under a trigger plan, a public insurance option would kick in if a state fails to meet federal insurance coverage goals.

"I would not be surprised at all to see that emerge" from the Senate's bill-merging discussions, Nichols says.

"Some kind of trigger is the best way to square the circle," he says. "It shows the right that there's no government takeover going on here, and moderate Democrats can get onboard."

But on Capitol Hill Wednesday, Reid said he wanted to note where he stands at the start of bill negotiations.

"I believe in a public option," he said, adding, pointedly: "Remember: I said I do."

A Win For Obama?

And that may be the path to what Obama could define as success on his signature domestic issue.

Even with a plan emerging that would contain an alternative to a full-blown public insurance option, and with considerably watered-down mandates for individuals to buy insurance and employers to pay for at least some coverage costs, the White House would most likely declare victory.

"The reason this is historic has almost nothing to do with the specifics," Nichols says, "but [with] the commitment now on the part of five congressional committees to make health insurance and health care affordable for all Americans — and to simultaneously bend the cost curve."

"We've never gotten this far before," he said.

But, for overhaul opponents, the game has only begun — and it will play out in the home districts of members of Congress facing re-election in 2010.

"If this is defeated, it will be defeated at the grass-roots level," says John Goodman, president and CEO of the National Center for Policy Analysis, which has gathered the signatures of more than 1.3 million who oppose the "nationalization" of health care.